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Purpose: The purpose of this study was to report the outcomes of a novel artificial endothelial replacement membrane implant for treating corneal edema after failed repeat endothelial keratoplasty (EK)., Design: This was a retrospective interventional case series., Methods: Patients with chronic corneal edema underwent removal of the EK graft and implantation of an artificial endothelial replacement membrane (EndoArt, EyeYon Medical, Israel) several months after 2 or more Descemet stripping endothelial keratoplasty procedures. The implant was secured to the posterior corneal surface using an air-gas bubble. Outcome measures included corrected distance visual acuity (logMAR), central corneal thickness, device-related complications, and ocular discomfort., Results: Five eyes of 5 patients underwent EndoArt implantation. Six months after surgery, the synthetic endothelial replacement membrane was well-centered and adherent to the posterior corneal surface, with improvement in central corneal transparency in all patients. Corrected distance visual acuity increased from mean 1.26 ± 0.25 (logMAR) preoperatively to 0.74 ± 0.44 (logMAR) postoperatively ( P = 0.06). Central corneal thickness significantly decreased from a mean of 805 ± 135 μm (excluding the EK graft) preoperatively to 588 ± 60 μm (excluding the EndoArt) postoperatively ( P = 0.015). No severe device-related complications developed after surgery, although most patients required more than 1 air-gas bubble injection to achieve complete implant adhesion. All patients experienced preoperative reduction in subjective ocular pain., Conclusions: Synthetic endothelial replacement membrane implantation improves central corneal transparency and visual acuity in patients with failed EK and guarded prognosis for repeat keratoplasty. No significant implant-related adverse events occurred after surgery., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: We herein present Descemet membrane endothelial keratoplasty (DMEK) as an effective surgical means of treatment for the management of interface fluid syndrome (IFS) in a series of cases with distant history of laser in situ keratomileusis (LASIK)., Methods: Three cases from a single institution were included. All patients had documented IFS in the setting of history of LASIK. All 3 patients underwent DMEK for the treatment of IFS. Visual acuity, clinical findings, pachymetry, endothelial cell count, and anterior segment optical coherence tomography were recorded., Results: We describe 3 cases of late-onset IFS that developed in eyes many years after LASIK (ranging from 15 to 31 years). All 3 patients had clinically significant corneal edema and evidence of poor endothelial function at the time of IFS diagnosis. DMEK was subsequently performed in each case. All 3 eyes showed resolution of corneal edema and improvement in best-corrected visual acuity after DMEK., Conclusions: DMEK can provide successful visual and anatomical recovery in patients who have had previous LASIK and experience late-onset IFS due to endothelial cell dysfunction., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To report a case of a retrocorneal fibrous membrane and corneal decompensation following uncomplicated phacoemulsification in an eye with pseudoexfoliative glaucoma., Method: Case report and literature review., Results: A monocular 83-year-old female developed corneal decompensation 1 year after uncomplicated cataract extraction via phacoemulsification. She had a history of pseudoexfoliative glaucoma and had undergone 3 rounds of selective laser trabeculoplasty in the same eye 3 years prior. Given the resulting corneal edema, the patient underwent Descemet's membrane endothelial keratoplasty, at which time a retrocorneal fibrous membrane was identified. Peeling of the membrane was surgically challenging and resulted in an intraocular hemorrhage intraoperatively and a small iridodialysis because the membrane had extended over the angle and iris. Postoperatively, the cornea cleared well, and vision improved significantly. However, vision was ultimately limited by macular pathology. Pathologic examination demonstrated Descemet's membrane with an attached fibrocellular membrane. Immunostaining for smooth muscle actin was positive within the membrane compatible with a retrocorneal membrane. We also present a review of the literature on modern causes of retrocorneal fibrous membranes., Conclusions: Retrocorneal fibrous membranes are encountered most commonly following corneal transplantation and may be surgically challenging to remove. We present the first case of a pathologically proven retrocorneal fibrous membrane following uncomplicated cataract surgery via phacoemulsification and selective laser trabeculoplasty., (Copyright © 2023 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Purpose: To report a challenging Descemet Membrane Endothelial Keratoplasty (DMEK) case, complicated by intraoperative aqueous misdirection and spontaneous anterior chamber fibrin reaction., Methods: A 70-year-old female affected by corneal edema due to Fuchs endothelial dystrophy underwent a triple procedure (cataract extraction - IOL implantation - DMEK surgery) in her left eye. This report illustrates the management of the intraoperative complications of aqueous misdirection syndrome and anterior chamber fibrin reaction., Results: Despite the optimal management of the posterior pressure and the thorough removal of the fibrinous reaction during the case, the DMEK graft was not completely unfolded and centred at the end of the surgical procedure. Nonetheless, the patient showed good long-term anatomical and functional recovery: at the last follow-up (2 years after surgery), central corneal thickness was 526 µm with a best corrected visual acuity of 20/25 and an endothelial cell density of 1112 cell/mm 2 ., Conclusion: Early recognition and prompt management of intraoperative aqueous misdirection syndrome and anterior chamber fibrin reaction during DMEK surgery is essential to ensure good functional and anatomical outcomes., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To assess the outcomes of deep anterior lamellar keratoplasty or penetrating keratoplasty at the scar and the edema stages., Methods: Forty-five patients (45 eyes) with keratoconus scar stage (scar group, n=26; penetrating keratoplasty a subgroup, n=7; deep anterior lamellar keratoplasty b subgroup, n=19) and keratoconus edema stage (edema group, n=19; penetrating keratoplasty c subgroup, n=12; deep anterior lamellar keratoplasty d group, n=7) who received penetrating keratoplasty or deep anterior lamellar keratoplasty from 2000 to 2022 were retrospectively studied. At 1, 6, and 12 months after surgery, the best-corrected visual acuity, astigmatism, spherical equivalent, corneal endothelial cell density, and complications were analyzed., Results: The best-corrected visual acuity and average corneal endothelial cell loss rate were not significantly different between the scar and edema groups (p>0.05). At 6 and 12 months after surgery, the astigmatism and spherical equivalent in the scar group were significantly lower than those in the edema group (p<0.05). The spherical equivalent of the deep anterior lamellar keratoplasty b subgroup was lower than that of the penetrating keratoplasty a subgroup in the scar group 6 months after surgery (p<0.05). In the edema group, there was no significant difference in spherical equivalent between subgroups (p>0.05). There were no significant differences in best-corrected visual acuity and astigmatism between subgroups within the two groups (p>0.05). In comparison to the scar group, the edema group experienced more complications. According to a survival analysis, there was no statistically significant difference between the scar group and the edema group regarding the progression of vision., Conclusions: In terms of the outcomes and prognosis for vision after keratoplasty with edema stage and scar stage, deep anterior lamellar keratoplasty may be as effective as penetrating keratoplasty.

Management of large acute corneal hydrops (ACH) has always been a challenge. Various medical and surgical management options have been used, such as topical steroids, cycloplegics, antiglaucoma medications, antibiotics, Descemet's membrane reposition, and pre-Descematic sutures, for the management of acute hydrops, but have shown limited benefit. We hereby describe a novel technique of appositional continuous overlay sutures along with air tamponade for surgical management of corneal edema following large ACH. In this technique, the epithelium is scraped to visualize the stromal cleft, and then corneal marking is done to locate the suture placement site. Next, a continuous overlay, 10-0 nylon suture is passed in a crisscross fashion, just like the laces of a corset. A small paracentesis is made to lower the intraocular pressure. Stromal fluid is milked out using two iris spatulas, simultaneous suture tension adjustment is done, and the knot is secured. Appropriate anterior chamber tamponade is achieved using air, paracentesis is hydrated, and a bandage contact lens is applied. We noted complete resolution of corneal edema within 2 weeks of the procedure, with significant improvement in visual acuity., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Introduction: Lamellar keratoplasties have had a great impact in the management of corneal edema due to endothelial dysfunction. Minimally invasive transplant techniques such as Descemet Membrane Endothelial Keratoplasty (DMEK) have helped to reduce the morbidity involved in performing penetrating keratoplasty in this type of patient. Even so, these are complex techniques that are not free of complications and require a long line of surgical learning and an even more demanding experience in postoperative management., Clinical Case: An 89-year-old woman suffering from Fuchs endothelial dystrophy and undergoing combined cataract and DMEK surgery presented stromal edema predominantly inferior and sectoral detachment of the graft 24 h after the intervention. After re-bubbling in consultations and 4 days later, the graft was observed rolled and free in the anterior chamber. She underwent re-DMEK with preservation of the original graft after 24 h, with de-epithelialization to optimize visualization. The graft was stained with trypan blue and the posterior stroma was protected with air. The graft was reimplanted under intraocular maneuvers and with an air bubble. 24 h after surgery, the adhered graft was observed, with a great decrease in stromal edema. One month later, the patient had a clear cornea, persistent complete graft adhesion, and visual acuity of 0.9., Conclusion: The discovery of free roll in the anterior chamber after DMEK surgery constitutes the most complex form of graft detachment. Corneal edema as well as the arrangement of the different intraocular structures are conditions to be considered for the surgical resolution of this complication. In many cases, surgical repositioning of the graft is feasible, which means saving costs without the need to use new donor corneal tissues., (Copyright © 2024 Sociedad Española de Oftalmología. Published by Elsevier España, S.L.U. All rights reserved.)

Objective: This study aimed to observe the clinical efficacy of precise suturing of posterior elastic layer fissures guided by intraoperative optical coherence tomography (OCT) in conjunction with anterior chamber puncture and drainage, and corneal thermokeratoplasty for the treatment of severe acute edematous keratoconus. Methods: Non-randomized controlled trial. Data were collected for a study involving 31 cases of acute edematous keratoconus patients who underwent surgical treatment at the Shandong Eye Hospital between June 2017 and July 2021. Among them, there were 30 male and 1 female patients, with an age range of 11 to 32 years and a mean age of (19.80±5.80) years. Eighteen patients in the study group underwent precise suturing of posterior elastic layer fissures guided by intraoperative OCT, in combination with anterior chamber puncture and drainage, and corneal thermokeratoplasty. Thirteen patients in the control group did not undergo suturing. Preoperative visual acuity, corneal edema diameter, corneal thickness, and posterior elastic layer fissure length were collected. Evaluation was performed using slit lamp microscopy, anterior segment OCT, and other methods to assess the time of initial postoperative corneal edema resolution and closure of the posterior elastic layer fissure. Deep lamellar keratoplasty was performed 2 to 4 weeks after edema resolution, and the corneal bed scar repair and visual acuity of the two groups were compared. Results: In the suturing group, the corneas of all 18 patients were accurately sutured to the deep stromal layer near the posterior elastic layer. The time for corneal edema resolution was 2.50 (1.00, 6.25) days in the suturing group and 7.00 (6.00, 10.50) days in the control group. The fissure healing time was 7.50 (7.00, 12.00) days in the suturing group and 14.00 (9.00, 14.00) days in the control group. The differences were statistically significant (all P <0.05). After 2 weeks, the central corneal thickness decreased to (529.80±174.50) μm in the suturing group and (612.00±205.12) μm in the control group. The suturing group showed accurate corneal suturing to the deep stromal layer near the posterior elastic layer, resulting in central corneal flattening, closure of voids in the stroma, and a significant decrease in corneal thickness. All 18 patients in the suturing group successfully completed deep lamellar keratoplasty, with 6 cases (6/18) experiencing mild graft bed leakage during surgery but without affecting the deep lamellar keratoplasty. One year postoperatively, the visual acuity (logarithm of the minimum resolution angle) was 0.23±0.12 in the suturing group and 0.33±0.11 in the control group, with a statistically significant difference ( P <0.05). Conclusions: In the treatment of severe acute edematous keratoconus, precise suturing of posterior elastic layer fissures guided by intraoperative OCT, in conjunction with anterior chamber puncture and drainage, and corneal thermokeratoplasty, can rapidly alleviate corneal edema and promote the healing of posterior elastic layer fissures. This approach achieves better visual outcomes for subsequent lamellar keratoplasty surgeries. The use of intraoperative OCT guidance allows accurate positioning of the posterior elastic layer fissure in terms of location, direction, and depth of corneal stromal voids, thereby assisting surgeons in precise suturing.

Purpose: To report the indications for keratoplasty and analyze trends in two decades in India., Methods: This was a retrospective review of eye bank registries of six tertiary eye care centers located in central and northern India from 2005 to 2021. The patterns of corneal pathology and changes in trends were analyzed., Results: Between 2005 and 2021, 13223 corneal grafts were performed in the six collaborating tertiary eye care centers. The most common indication for keratoplasty in both decades was corneal ulcer (41.1%), followed by corneal scar (25.5%), failed graft (12.0%), post-cataract surgery corneal edema (11.7%), corneal dystrophies (3.1%), corneal ectasia (1.8%), corneal trauma (0.3%), congenital corneal opacity (0.3%), and others (4.1%). An increasing trend was seen in corneal ulcers, failed grafts, and keratoconus. A reducing trend was seen in corneal scar and aphakic bullous keratopathy. There was no change in pseudophakic bullous keratopathy and Fuchs endothelial corneal dystrophy., Conclusion: Corneal ulcers, corneal scars, failed grafts, and post-cataract surgery corneal edema remained the foremost indications for keratoplasty in two decades in India. An increasing trend was seen in corneal ulcers and failed grafts which are of concern as these indications carry a poorer outcome. Capacity building in lamellar keratoplasty techniques is the need of the hour as pseudophakic bullous keratopathy was an important indication, and an increasing trend was noticed in keratoconus., (Copyright © 2023 Copyright: © 2023 Indian Journal of Ophthalmology.)

Significance: Some patients show poor visual outcomes after Descemet stripping automated endothelial keratoplasty. In such cases, secondary Descemet membrane endothelial keratoplasty can be performed to achieve complete visual recovery. Anterior segment optical coherence tomography (AS-OCT) is a valuable tool for the follow-up of posterior lamellar keratoplasty outcomes and complications., Purpose: This study aimed to report the clinical outcome of secondary Descemet membrane endothelial keratoplasty for managing poor visual results in a patient with graft failure after a previous Descemet stripping automated endothelial keratoplasty, highlighting the importance of AS-OCT in the follow-up of endothelial keratoplasty., Case Report: A 38-year-old woman with high myopia underwent Descemet stripping automated endothelial keratoplasty for bullous keratopathy after explantation of an angle-supported phakic intraocular lens. Two years after keratoplasty, the patient experienced poor visual acuity (counting fingers), and significant corneal edema was observed on clinical examination hindering visualization of the anterior chamber structures. Anterior segment optical coherence tomography showed a failed and thickened graft adhering well to the recipient cornea in an anterior chamber without other comorbidities. Therefore, the graft was removed and replaced with a Descemet membrane endothelial keratoplasty graft without any complications. One year later, the clinical outcome was evaluated by comparing the pre-operative and post-operative best-corrected visual acuity, biomicroscopy findings, endothelial cell density, and corneal central thickness., Conclusions: Anterior segment optical coherence tomography is an important tool when deciding on the surgical technique to be applied and for the post-surgical monitoring of endothelial corneal grafts. This case demonstrates the successful management of Descemet stripping automated endothelial keratoplasty graft failure with Descemet membrane endothelial keratoplasty graft, highlighting the importance of AS-OCT in detecting complications such as graft dislocation and primary graft failure. In addition, corneal thickness measured using AS-OCT serves as a critical predictor of graft failure, as observed in this case., Competing Interests: Conflict of Interest Disclosure: None of the authors have reported a financial conflict of interest., (Copyright © 2023 American Academy of Optometry.)

Purpose: The aim of this study was to define risks for corneal transplantation associated with fibrous ingrowth among first-time transplant recipients., Methods: We performed a retrospective case-control study of patients with a histopathologic diagnosis of fibrous ingrowth between 2002 and 2019. Patients with fibrous ingrowth from a first corneal specimen were included. Those with incomplete records were excluded. A 1:2 case-control ratio was used. Controls were matched using surgical indication, surgery year, transplantation method, sex, and age., Results: Seventy-eight eyes (76 patients) were included and matched with 160 control eyes. The incidence of fibrous ingrowth found on a first corneal transplant was 0.6% per year. The most common keratoplasty indications were pseudophakic corneal edema (n = 25, 32%) and aphakic corneal edema (n = 15, 19%). Cases were more likely to have a history of ocular trauma (odds ratio [OR], 2.94; 95% CI, 1.30-6.30; P = 0.007), uveitis (OR, 2.73; 95% CI, 1.12-6.63; P = 0.022), retinal detachment or previous retinal surgery (OR, 2.40; 95% CI, 1.34-4.30; P = 0.003), glaucoma tube-shunt surgery (OR, 2.70; 95% CI, 1.29-5.65; P = 0.007), aphakia (OR, 3.02; 95% CI, 1.61-5.67; P = 0.0004), or iris derangement (OR, 10.52; 95% CI, 5.45-20.30; P <0.0001). A multivariate logistic regression model using iris derangement, history of ocular trauma, history of uveitis, and history of cataract surgery demonstrated 81% sensitivity and 66% specificity in predicting presence of fibrous ingrowth., Conclusions: A history of ocular trauma, uveitis, retinal detachment or previous retinal surgery, glaucoma tube-shunt surgery, aphakia, and iris derangement are risks for detecting fibrous ingrowth among first-time keratoplasty recipients. Patients with these conditions should be monitored closely for corneal decompensation., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The aim of this study was to evaluate the visual, pachymetric, tomographic, and biomicroscopic findings in a series of cases with laser in situ keratomileusis (LASIK) flap interface fluid syndrome (IFS) after Descemet membrane endothelial keratoplasty (DMEK)., Methods: Six cases were included in this study; all patients had a history of LASIK and underwent DMEK for the treatment of bullous keratopathy. After uneventful surgery, all patients presented with corneal edema and IFS under the LASIK flap, which was demonstrated with anterior segment optical coherence tomography (AS-OCT). Visual acuity, clinical findings, pachymetry, endothelial cell count, and AS-OCT were documented during the management of these cases., Results: IFS appears 2.33 days (±1.03) after DMEK. One case improved with conservative treatment. In 5 cases, the LASIK flap was lifted, the fluid was drained, and the flap was replaced. The mean best-corrected visual acuity after fluid drainage was 0.44 logMAR (range 0.18-1.0) and mean central corneal thickness was 538 μm ± 160. Total resolution of the IFS was achieved at 14.5 days (range 4-30) after DMEK. AS-OCT showed resolution of the flap interface in 5 of 6 cases, while 1 patient required second DMEK due to reaccumulation of the interface fluid., Conclusions: IFS can occur after DMEK in patients with previous LASIK. AS-OCT is a valuable tool for monitoring these cases preoperatively and postoperatively. Early surgical management is often needed to achieve resolution., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Prcis: Primary congenital glaucoma (PCG) in Tunisian children seems to be characterized by a high prevalence of inherited and advanced forms of the disease. Primary combined trabeculotomy trabeculectomy (CTT) allowed satisfactory long-term intraocular pressure (IOP) control and reasonable visual outcome., Purpose: To report the long-term outcome of CTT as the initial glaucoma surgery in children with PCG., Methods: Retrospective analysis of children who underwent primary CTT for PCG between January 2010 and December 2019. The main outcome measures were IOP reduction, corneal clarity, complications, refractive errors, and visual acuity (VA). Success was defined as IOP <16 mm Hg without (complete) or with (qualified) antiglaucoma medication. The WHO criteria of vision loss were used to categorize visual impairment (VI)., Results: Of 62 patients, 98 eyes were enrolled. At the last follow-up, the mean IOP was reduced from 22.7 ± 4.0 mm Hg to 9.7 ± 3.9 mm Hg ( P < 0.0001). The complete success rate was 91.6%, 88.4%, 84.7%, 71.6%, 59.7%, and 54.3%, at the first, second, fourth, sixth, eighth, and tenth year, respectively. Follow-up averaged 42.1 ± 28.4 months. Preoperatively, 72 eyes (73.5%) had significant corneal edema versus 11 eyes (11.2%) at the end of the follow-up ( P < 0.0001). Endophthalmitis was encountered in one eye. Myopia was the most common refractive error (80.6%). Data on Snellen VA were available for 53.2% of the patients; 33.3% achieved a VA ≥6/12, 21.2% had mild VI, 9.1% had moderate VI, 21.2% had severe VI, and 15.2% were blind. The failure rate was statistically correlated to the early disease onset (<3 mo) and to preoperative corneal edema ( P = 0.022 and P = 0.037, respectively)., Conclusion: Primary CTT seems to be a good procedure in a population with advanced PCG at presentation, problematic follow-up visits, and limited resources., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To assess corneal endothelial cell (CE) loss after pars plana (PP) and pars limbal (PL) insertion of a Baerveldt glaucoma implant (BGI)., Design: Retrospective multicenter interventional comparative study., Methods: We studied central CE loss for 5 years after BGI surgery in 192 eyes., Results: The prevalence of bullous keratopathy (BK) was greater in the PL cohort than in the PP cohort (P = .003). The CE loss after simultaneous PP vitrectomy and tube insertion into the vitreous cavity was 11.9% in the first year, which was greater than that of 2.9% in eyes where the tube was inserted simply into the vitreous cavity after a prior vitrectomy (P = .046). The annual percentage CE loss after the first year decreased unidirectionally in both of those groups and was 1.3% and 1.0% in the fifth year, respectively (P < .001). For limbal insertion, the CE loss in the simple PL cohort was biphasic, decreasing from 10.5% in the first year to 7.0% in the fifth year. Simultaneous cataract and BGI surgery enhanced the CE loss slightly in the first year in the PP and PL cohorts to 13.0% and 14.0%, respectively. However, these increases were not significant (P = .816 and .358, respectively). Low preoperative CE density (P < .001) and insertion site (P = .020) were significant risk factors for the development of BK., Conclusions: CE loss in the PL and PP cohorts was biphasic and unidirectional, respectively. The difference in annual CE loss became evident over time. PP tube implantation may be advantageous when the preoperative CE density is low., (Copyright © 2023 Elsevier Inc. All rights reserved.)

A woman in her 60s was referred to us for management of poor vision following cataract surgery in the right eye. She had undergone manual small incision cataract surgery 12 weeks earlier. Slit-lamp biomicroscopy revealed corneal oedema, a horizontal line at the upper border and the adhered inferior border of detached Descemet's membrane (DM). Clinical diagnosis of impacted Descemet's membrane detachment (DMD) was considered.Surgical intervention with manual schisis and intracameral injection of air was planned. Using the 'push technique,' we tried to place the tip of the 27 gauge cannula between the back of the cornea and detached DM. The tip of the 27 gauge cannula was behind the impacted DM, and air injection was unsuccessful. Using the back-up the 'pull technique,' bent tip of the 27 gauge cannula was used to pull the impacted DMD. This manoeuvre, disimpacted the inferior border and the air bubble, was injected using the 27 gauge cannula. The air bubble unfolded and reattached the DM successfully., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Ripasudil, a rho-kinase inhibitor, has gained popularity as an adjunctive therapy after Descemet stripping only to hasten visual recovery. Ripasudil has been shown to increase corneal endothelial cell proliferation and intercellular adhesion, and decrease endothelial cell apoptosis. We present 4 cases in which persistent corneal edema after various anterior segment surgeries was successfully treated with topical ripasudil, and 1 case in which corneal edema did not improve with use of ripasudil., Methods: Retrospective chart review revealed 5 patients treated with topical ripasudil for persistent corneal edema that failed to improve with conventional, nonsurgical treatments., Results: In each case, the patient had symptomatic, persistent, focal corneal edema which followed a surgical procedure in the anterior segment. The various etiologies of corneal edema included graft failure after Descemet stripping endothelial keratoplasty, a failed penetrating keratoplasty, and 3 cases of pseudophakic corneal edema. These patients experienced improved vision and partial or complete resolution of corneal edema after 2 to 4 weeks of topical ripasudil administered 4 times daily. One patient with pseudophakic bullous keratopathy had edema that initially improved on topical ripasudil, but after cessation of the medication, developed progressive corneal edema and required endothelial keratoplasty., Conclusions: In patients with focal corneal edema resulting from surgical trauma to the endothelium who failed to clear over time with conservative measures, topical ripasudil was shown to be an effective treatment option that in most cases improved vision and helped reduce the need for endothelial transplantation., Competing Interests: Conflicts of interest statement: The authors have no funding or conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To describe the use of glycerin in improving media clarity in cases with edematous cornea., Methods: Retrospective case series including patients with posterior segment pathologies needing surgical invention and having corneal edema. Each case was studied for the role of topical application of glycerin instead of viscoelastic agents and the course of surgery. The cases were followed up for minimum 3 months duration., Results: Six cases with corneal edema having posterior segment pathology underwent surgery with intraoperative topical application of glycerin. The corneal edema was seen to clear with progression of surgery and was maintained until the end of surgery. Procedures such as vitreoretinal surgery, identification of break, internal limiting membrane peeling, intraocular lens explantation, scleral indentation, Descemet stripping endothelial keratoplasty graft removal, and subretinal band removal could be performed in these cases., Conclusion: Intraoperative glycerin use during vitreoretinal surgeries is helpful in improving the corneal clarity and maintaining it till the end of surgery.

Purpose: The goal of this study was to compare outcomes of Descemet stripping endothelial keratoplasty (DSEK) in eyes with glaucoma and abnormal anatomy to eyes with Fuchs endothelial corneal dystrophy (FECD)., Methods: In a retrospective interventional series of all cases of DSEK between April 1, 2006, and November 30, 2015, recipient diagnosis, preoperative glaucoma status, concurrent surgical procedures, and graft outcomes were recorded. Graft survival, risk of rejection, and subsequent glaucoma surgery were estimated by using Kaplan-Meier analysis with risk factors determined by proportional hazard models., Results: Of 703 DSEKs in 666 eyes (509 subjects), the main recipient diagnoses were FECD (n = 496), pseudophakic corneal edema (n = 112), and failed graft (n = 83). Glaucoma was present in 150 cases before DSEK. Overall graft survival was 85%, 75%, and 71% at 5, 10, and 12 years, respectively, and for FECD without glaucoma was 95%, 89%, and 87% at 5, 10, and 12 years, respectively. Independent risk factors for graft failure included recipient diagnoses of pseudophakic corneal edema (HR = 8.3, P < 0.001), failed graft (HR = 6.4, P < 0.001), and preoperative medical glaucoma (HR = 7.1, P < 0.001) or surgical glaucoma (HR = 12.3, P < 0.001). Preoperative glaucoma treated by previous surgery resulted in graft survival of 28% at 10 years. Preoperative glaucoma was associated with an increased risk of graft rejection (HR = 6.8, P < 0.001) and subsequent glaucoma surgery (HR > 17.4, P < 0.001)., Conclusions: Preoperative glaucoma increases the risk of graft failure, graft rejection, and needing subsequent glaucoma surgery in the first decade after DSEK. With previous glaucoma surgery, DSEK graft survival was more favorable compared with published reports of Descemet membrane endothelial keratoplasty., Competing Interests: S. V. Patel is a consultant to GlaxoSmithKline, Emmecell, and AbbVie Inc, and has had recent consulting relationships with Senju Pharmaceuticals and Santen Inc; these activities are unrelated to the topic of this manuscript. S. V. Patel developed the V-FUCHS instrument, which Mayo Clinic licenses to Iris Medicine and Aerie Pharmaceuticals. S. V. Patel and D. O. Hodge have filed a patent application for predicting corneal improvement from Scheimpflug imaging, which is not related to the topic of this manuscript. The remaining authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The purpose of this study was to evaluate 15-year outcomes of Descemet stripping endothelial keratoplasty (DSEK)., Methods: We retrospectively reviewed an initial, consecutive series of 350 DSEK cases in 290 patients (mean age 69 years), performed between December 2003 and December 2005 for Fuchs dystrophy (86%), pseudophakic/aphakic bullous keratopathy (10%), or failed penetrating keratoplasty (4%). Outcomes included best spectacle-corrected visual acuity (BSCVA), endothelial cell density (ECD), and graft failure (defined as regraft for any reason or persistent loss of stromal clarity)., Results: At 15 years, 46 of 350 DSEK grafts (13%) had failed, 155 (44%) were in patients who died, and 84 of the remaining 149 grafts (56%) were examined. After accounting for loss to follow-up, the probability of graft failure was 7% at 5 years, 16% at 10 years, and 23% at 15 years. The main risk factor for late endothelial failure was preoperative glaucoma (hazard ratio: 4.4 for medically managed and 24 for surgically managed glaucoma). The probability of an immunologic rejection episode was 7% by 1 year, 14% by 10 years, and 17% by 15 years. The median donor ECD decreased from 3030 cells/mm 2 before DSEK to 1973 cells/mm 2 at 6 months (36% loss) and 705 cells/mm 2 at 15 years (78% loss). The median BSCVA, including the eyes with ocular comorbidity, was 20/60 preoperatively, 20/40 at 3 through 12 months, and 20/30 from 2 to 15 years., Conclusions: DSEK provided excellent long-term visual rehabilitation and graft survival in this early cohort, performed when the technique was still being refined., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: This study aimed to present a novel technique for Descemet membrane endothelial keratoplasty (DMEK) in pseudophakic and vitrectomized eyes., Methods: The sterile air was injected into the posterior eye segment (anterior vitreous cavity) as a barrier to prevent the fluid of the vitreous cavity flowing into the anterior chamber, levitating the iris-lens diaphragm to flatten the anterior chamber during the surgery. This approach assists in the unfolding of the donor endothelial graft, helping to perform DMEK surgery on patients with a posterior intraocular lens (IOL) and vitrectomy., Results: Four cases presented with corneal endothelial decompensation (pseudophakic bullous keratopathy) with previous IOL implantation and vitrectomy underwent DMEK with this technique. The Descemet endothelial graft unfolding time after air injection was 68.75 ± 8.96 seconds. No graft displacement occurred during the surgery. The uncorrected and corrected distance visual acuities were improved in 3 of 4 patients. The corneas were transparent, and there was no graft detachment observed postoperatively in all 4 patients., Conclusions: The posterior eye segment air injection can reduce the difficulty of unfolding the DMEK graft in patients after IOL implantation and vitrectomy and the potential intraoperative and postoperative complications, allowing for easy performance of DMEK surgery on pseudophakic and vitrectomized eyes for corneal endothelial dysfunction., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The purpose of this study was to compare glaucoma therapy escalation (GTE), graft survival, vision, and glaucoma following penetrating keratoplasty (PK group) and Descemet stripping automated endothelial keratoplasty (DSAEK group) to treat pseudophakic bullous keratopathy (PBK)., Methods: This cohort included cases of PBK managed with PK from 2009 to 2014. We compared the incidences and determinants of GTE, graft survival, and visual disability. P < 0.05 was statistically significant., Results: There were 58 eyes in the PK group and 117 eyes in the DSAEK group. The incidence of GTE in the PK and DSAEK groups at the last follow-up was 34.2% (95% confidence interval [CI]: 19.5-48.9) and 46.6% (95% CI: 27.7-65.4), respectively. The risk of GTE was similar between the groups (relative risk [RR] = 1.36 [95% CI: 0.94-1.98], P = 0.12). GTE was significantly associated with graft survival in the PK group (RR = 3.25 [95% CI: 1.5-7.0], P < 0.001) and the DSAEK group (RR = 3.77 [95% CI: 2.6-5.6], P < 0.001). Glaucoma ( P = 0.001) and previous keratoplasty ( P < 0.001) were significant predictors for GTE. At the final follow-up visit, severe visual disability was not significantly different between the groups (RR = 0.9 [95% CI: 0.3-2.9], P = 0.88). There was a statistically significant improvement in vision after DSAEK ( P < 0.001) but not after PK ( P = 0.67)., Conclusion: GTE was similar in eyes with PBK managed by PK or DSAEK. Glaucoma and previous keratoplasty were predictors of GTE post-keratoplasty. DSAEK gave better visual outcomes than PK for managing PBK., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Middle East African Journal of Ophthalmology.)

Corneal endothelium is the innermost layer of the cornea which has both barrier and pump function and very important to maintain cornea clarity. Unlike epithelium, endothelium does not have regenerative potential; hence, endothelial damage or dysfunction could lead to corneal edema and visual impairment. Advanced corneal transplantation which involves selective replacement of dysfunctional endothelium has led to improved and faster visual rehabilitation. But in recent times, alternative therapies in the management of corneal edema and endothelial diseases have been reported. In this review, we aim to give a comprehensive review of various strategies for the management of corneal endothelial dysfunction in order to give treatment which is precisely tailored for each individual patient. A review of all peer-reviewed publications on novel strategies for the management of endothelial dysfunction was performed. The various approaches to the management of endothelial dysfunction are compared and discussed. Shortage of human donor corneas globally is fuelling the search for keratoplasty alternatives. Corneal endothelial dysfunction can be caused following surgery, laser or corneal endothelial dystrophies which could be amenable to treatment with pharmacological, biological intervention and reverse the endothelial dysfunction in the early stages of endothelial failure. Pharmacological and surgical intervention are helpful in cases of good peripheral endothelial cell reserve, and advanced cases of endothelial cell dysfunction can be targeted with cell culture therapies, gene therapy and artificial implant. Treatment strategies which target endothelial dysfunction, especially FECD in its early stages, and gene therapy are rapidly evolving. Therapies which delay endothelial keratoplasty also are evolving like DSO and need more studies of long-term follow-up and patient selection criteria.

Purpose: Congenital hereditary endothelial dystrophy (CHED) is a rare, autosomal recessive, monogenic corneal condition with variable expressivity. Often presents in bilateral symmetrical progressive corneal cloudiness that starts in the early infancy. It is characterized by increased corneal thickness, profound corneal edema, and thickening of the Descemet membrane due to endothelial dysfunction. The published literature lacks uniform guidelines for grading corneal cloudiness and management algorithm for CHED cases. This article focuses on applying newer investigational modalities to fine-tune surgical outcomes and more recent CHED management strategies., Methods: This comprehensive literature review was performed based on a search on the PubMed database of relevant CHED articles focusing on those published in the last 7 years. A total of around 70 articles were reviewed, and 17 of them were included in this review. These include systemic reviews, randomized controlled clinical trials, cohort studies, case-controlled studies, and case series., Results: Corneal cloudiness grading in CHED using subjective and objective methods using Anterior Segment Optical Coherence Tomography (AS-OCT) and densitometry using Scheimpflug imaging can help select appropriate management plan for CHED cases. DSAEK outscores penetrating keratoplasty with much fewer complications and expedites visual recovery, which helps mitigate amblyopia., Conclusion: Managing cases of CHED has been a challenge due to the dilemma in timing and appropriate surgical method selection and lack of definitive medical or other conservative approaches. Currently, DSAEK has shown favorable results in cases of CHED. However, appropriate staging of CHED and selecting the appropriate management approach appears to play a critical role in managing such cases. Besides these, novel treatment modalities such as nonsteroidal anti-inflammatory agents (NSAIDS) that target restoring water-flux activity in subtype of CHED and gene editing using CRISPR-Cas9 are promising paradigm treatment modalities.

Purpose: To determine whether local corneal thickness changes observed with optical coherence tomography (OCT) can detect subclinical corneal edema in Fuchs endothelial corneal dystrophy (FECD)., Setting: Retrospective cohort study., Methods: A series of patients presenting FECD who underwent cataract surgery alone (45 eyes) or with concomitant Descemet membrane endothelial keratoplasty (triple procedure; 117 eyes). The study reviewed medical records, collected the preoperative corneal thickness map and calculated the differences and ratio of corneal thickness measured at 5, 7, and 9 mm from the central corneal thickness. Area under the receiver operating characteristic curves (AUCs) were calculated and thresholds were selected to obtain a specificity of 90%., Results: The median difference between 5- and 2-mm corneal thickness in the supra-nasal quadrant (∆5-2mmSN) was 38 µm (interquartile range 34-46) in the cataract group and 17 µm (2-38) in the triple procedure group (P < .001). The corneal thickness ratios of supra-nasal 5- to 2-mm (R5/2mmSN) and 7- to 2-mm (R7/2mmSN) were 1.07 (1.06-1.08) and 1.15 (1.13-1.17)] in the cataract group and 1.03 (1.00-1.06) and 1.09 (1.06-1.14) in the triple procedure group (P < .001). The probability of corneal edema was increased 7-fold with ∆5-2mm SN < 27 µm (AUC = 0.76) and 9.4- and 7.4-fold with R5/2mmSN and R7/2mmSN < 1.045 (AUC = 0.77) and 1.118 (AUC = 0.76), respectively., Conclusions: Local changes in corneal thickness may be useful in detecting preclinical corneal edema, especially in patients with FECD undergoing cataract surgery., (Copyright © 2022. Published by Elsevier Inc.)

This article reports a novel surgical technique of partial-thickness compression sutures without descemetopexy with air or gas for the management of acute hydrops in keratoconus. Two patients presented with localized corneal edema with a Descemet membrane (DM) tear in the left eye. Tomography of the right eye revealed localized steepening with increased maximum keratometry and decreased central pachymetry. They were diagnosed with keratoconus in the right eye and acute corneal hydrops (ACH) in the left eye. Compression sutures were passed through the stroma without touching the DM. The anterior chamber was not entered at all at any point during the surgery. Resolution of edema was noted intraoperatively itself. Further resolution of edema was noted from the first postoperative day which markedly reduced within the first week. A corneal scar with no edema was seen at six weeks. In both the patients, vision at presentation was counting fingers close to face which improved to 20/60 and 20/50, respectively, at the last visit.

Purpose: The purpose of this study was to describe the incidence of graft detachment after Descemet membrane endothelial keratoplasty (DMEK) without postoperative supine posturing., Methods: A total of 106 eyes of 84 patients with Fuchs endothelial corneal dystrophy or bullous keratopathy (BK) were operated by a single experienced surgeon with DMEK with a 99% anterior chamber air bubble fill, recovered in an upright (seated) position, and then discharged without instructions to remain supine. Postoperatively, all eyes were evaluated for graft detachment through anterior segment optical coherence tomography at predetermined intervals (1 d, 1 wk, and 1 mo). Detachments were regarded as clinically significant if they subtended 30% of the total graft surface area or involved the visual axis., Results: Clinically significant graft detachments were observed in 23 of 106 eyes (22%) in the no-supine posturing cohort, including 22 of 85 eyes (26%) operated for Fuchs endothelial corneal dystrophy and 1 of 21 eyes (5%) operated for BK. Compared with a historical comparison group of eyes undergoing DMEK with 48 hours of postoperative supine posturing, the risk of graft detachment was not increased. In both cohorts, 6% of operated eyes required regrafting for either persistent detachment or primary graft failure. No additional intraoperative or postoperative complications were experienced., Conclusions: Particularly in eyes operated for BK, the supine posturing requirement after DMEK may be eliminated without increasing the absolute risk for clinically significant graft detachment., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To compare the efficacy and safety of ultrathin Descemet stripping (automated) endothelial keratoplasty (UT-DS(A)EK) versus Descemet membrane endothelial keratoplasty (DMEK) for the treatment of Fuchs endothelial dystrophy (FED) and bullous keratopathy (BK)., Design: Systematic review and meta-analysis., Methods: Literature containing DMEK and UT-DSAEK were searched in the Cochrane Database of Systematic Reviews, PubMed, EMBASE, LILACS, and through manual reference searching. Studies were included that measured the outcome of interventions-including best corrected visual acuity (BCVA), endothelial cell density (ECD), and postoperative complications, especially graft detachment with the need of re-bubbling, graft rejection, graft failure, and postoperative elevated intraocular pressure (IOP)-in patients with FED and BK. Included outcomes were pooled as standardized mean differences (SMD) or risk ratios (RR) using random effects models. Inter-study heterogeneity was assessed using the Q-test and I 2 statistic., Results: Seven (of 163) studies met all the inclusion and exclusion criteria. Meta-analysis showed a significantly better BCVA 12 months postoperatively, but an increased re-bubbling rate in eyes after DMEK compared with eyes after UT-DS(A)EK (BCVA: SMD = 0.50 [95% CI 0.27-0.74] and re-bubbling rate: RR = 0.33 [95% CI 0.16-0.67]). All other parameters did not differ significantly between both interventions, although estimates were imprecise (graft failure: RR = 0.65 [95% CI 0.18-2.30], graft rejection: RR = 1.40 [95% CI 0.27-7.30], and postoperative intraocular pressure elevation: RR = 1.14 [95% CI 0.60-2.18]). Postoperative SMDs of ECD could not be evaluated due to significant heterogeneity between studies., Conclusions: Although the improvement in BCVA was higher after UT-DS(A)EK than after conventional DS(A)EK, the BCVA after DMEK was still superior. The complication rates were comparable for both procedures, except for the higher rate of re-bubbling after DMEK., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Long-term comparative data of phacoemulsification combined with endoscopic cyclophotocoagulation (phaco-ECP) versus phacoemulsification (phaco) alone in dogs are rare., Objectives: To investigate the effects of ECP on postoperative intraocular pressure (IOP) and complications after phaco in dogs with normal IOP., Methods: Medical records of IOP, conjunctival hyperemia, corneal edema, aqueous flare, posterior synechia, intraocular fibrin, and posterior capsule opacification (PCO) formation in 15 canine eyes that underwent phaco-ECP and 36 eyes that underwent phaco alone were evaluated retrospectively. ECP was applied when either the iridocorneal angle or the ciliary cleft was narrow or closed., Results: The IOP of the phaco-ECP group persisted within the normal range postoperatively. The phaco-ECP group had a shorter period of dorzolamide use than did the phaco group. PCO was formed earlier in the phaco-ECP group than in the phaco group. The phaco-ECP group showed more severe corneal edema than the phaco group at every follow-up visit. Posterior synechia was more severe in the phaco-ECP group than in the phaco group from two weeks until the last follow-up., Conclusions: Although ECP might cause more postoperative complications such as corneal edema and posterior synechia, it could effectively reduce the incidence of IOP increase after phaco in dogs with a high risk of postoperative glaucoma., Competing Interests: The authors declare no conflicts of interest., (© 2023 The Korean Society of Veterinary Science.)

Purpose: The aim of this study was to review the postoperative course and imaging features of 7 eyes that presented with corneal hydrops after Bowman layer (BL) transplantation was performed for advanced keratoconus to determine the potential mechanisms of hydrops formation., Methods: A retrospective analysis was performed of 7 eyes of 5 patients with advanced keratoconus that underwent midstromal BL transplantation at 2 tertiary referral centers and developed acute corneal hydrops on average 64 (±30) months (range 14-104 months) postoperatively. Corneal tomography and anterior segment optical coherence tomography (AS-OCT) images were reviewed to document the postoperative and posthydrops course., Results: For all eyes, the post-BL transplantation course was uneventful until hydrops development. Despite stable postoperative topographies in 5 of 7 eyes, eyes developed hydrops with typical hypodense areas on AS-OCT that were limited to the stromal layers posterior to the BL graft. With AS-OCT (6/7 eyes), 2 eyes showed a break in Descemet membrane, whereas Descemet membrane was intact across the cornea in 2 eyes; in 2 eyes, the images were inconclusive. All patients admitted to continued eye rubbing, and all but 1 had a clinically significant allergy and/or atopic constitution. Most eyes (5/7) showed a relatively quick (visual) recovery within 1 to 4 months after hydrops., Conclusions: Hydrops formation in keratoconic corneas after midstromal BL transplantation may indicate that a break in Descemet membrane is secondary to hydrops development (and not vice versa). With a midstromal BL graft in situ limiting hydrops dimensions, resolution of the hydrops seemed relatively quick with recovery to prehydrops visual acuity in most eyes., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Descemet membrane endothelial keratoplasty (DMEK) is the preferred method for treating corneal endothelial dysfunction, such as Fuchs endothelial corneal dystrophy (FECD). The surgical indication is based on the patients' symptoms and the presence of corneal edema. We developed an automated tool based on deep learning to detect edema in corneal optical coherence tomography images. This study aimed to evaluate this approach in edema detection before Descemet membrane endothelial keratoplasty surgery, for patients with or without FECD., Methods: We used our previously described model allowing to classify each pixel in the corneal optical coherence tomography images as "normal" or "edema." We included 1992 images of normal and preoperative edematous corneas. We calculated the edema fraction (EF), defined as the ratio between the number of pixels labeled as "edema," and those representing the cornea for each patient. Differential central corneal thickness (DCCT), defined as the difference in central corneal thickness before and 6 months after surgery, was used to quantify preoperative edema. AUC of EF for the edema detection was calculated for Several DCCT thresholds and a value of 20 µm was selected to define significant edema as it provided the highest area under the curve value., Results: The area under the curve of the receiver operating characteristic curve for EF for the detection of 20 µm of DCCT was 0.97 for all patients, 0.96 for Fuchs and normal only and 0.99 for non-FECD and normal patients. The optimal EF threshold was 0.143 for all patients and patients with FECD., Conclusions: Our model is capable of objectively detecting minimal corneal edema before Descemet membrane endothelial keratoplasty surgery., Translational Relevance: Deep learning can help to interpret optical coherence tomography scans and aid the surgeon in decision-making.

Purpose: To assess risk factors for repeat keratoplasty after endothelial keratoplasty (EK)., Design: Retrospective cohort study., Methods: EK procedures performed between 2013 and 2018 in the IRIS Registry (Intelligent Research in Sight) were identified., Study Population: Patients aged 18 years and older who underwent EK., Main Outcome Measures: (1) Risk factors for repeat keratoplasty and (2) complication rates after EK. A Kaplan-Meier survival analysis was used to determine the probability of repeat keratoplasty. A multivariable shared frailty survival model was used to assess risk factors., Results: A total of 59 344 procedures were identified in the registry, of which 30 600 EK procedures met the inclusion criteria for the analysis. The probability of repeat keratoplasty was 17.4% (95% CI 16.7-18.0) at 5 years. Risk factors for repeat keratoplasty include postoperative rebubbling procedure (HR 2.24, 95% CI 2.05-2.45), prior failed graft (HR 2.07, 95% CI 1.84-2.32) or bullous keratopathy (HR 1.47, 95% CI 1.33-1.61) vs Fuchs dystrophy as surgical indication; subsequent routine cataract surgery (HR 1.61, 95% CI 1.45-1.79), as well as subsequent (HR 1.53, 95% CI 1.39-1.69) and prior/concurrent (HR 1.23, 95% CI 1.11-1.36) glaucoma surgery or history of glaucoma (HR 1.24, 95% CI 1.14-1.35). Medicaid (HR 1.47, 95% CI 1.13-1.92), military/government (HR 1.29, 95% CI 1.03-1.60), Medicare Fee-for-Service (HR 1.17, 95% CI 1.05-1.31) or Medicare Managed (HR 1.17, 95% CI 1.01-1.36) insurances vs private insurance, as well as Black vs White race (HR 1.25, 95% CI 1.11-1.40) and smoking (HR 1.16, 95% CI 1.05-1.27) were also associated with an increased risk of undergoing repeat keratoplasty., Conclusions: Black race, government-based insurance plans, and smoking were identified as independent factors associated with repeat keratoplasty in addition to history of glaucoma, glaucoma surgery, and prior graft failure or bullous keratopathy as surgical indication., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to report the 22-year clinical outcome of a patient who underwent endokeratoplasty., Methods: To report the clinical outcomes of 37-year-old male who underwent endokeratoplasty for decompensated Fuchs endothelial dystrophy in 1998., Results: After subsequent cataract surgery and iridoplasty, at 22 years post endokeratoplasty, the Snellen best spectacle-corrected visual acuity is 20/20 (-5.50 sphere -3.00 cylinder at 135 degrees), endothelial cell count is 645 cells/mm 2 , central corneal thickness is 644 μm, and the cornea remains clear with no evidence of graft rejection or failure., Conclusions: To the best of our knowledge, this is the longest reported outcome for selective endothelial replacement. The patient undergoing endokeratoplasty can achieve an excellent visual acuity and long-term graft survival., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The purpose of this study was to report a case of corneal endothelial dysfunction and subsequent corneal edema in a patient with digoxin toxicity., Method: This was a case report., Results: A 77-year-old woman diagnosed with open-angle glaucoma and treated with a topical prostaglandin analog for 5 years developed blurred vision and photopsia in both eyes. Systemic medications included digoxin, furosemide, apixaban, amlodipine, enalapril, and simvastatin. Ocular examination revealed folds in Descemet membrane and corneal stromal edema in both eyes, with normal fundoscopy. Ancillary tests revealed elevated serum digoxin levels. No intervention other than discontinuation of digoxin was initiated. The corneal edema improved after that and resolved in the next 2 weeks., Conclusions: We encountered 1 case of corneal edema secondary to corneal endothelial dysfunction in a patient with digoxin toxicity. Special care should be taken to elicit a complete history because ocular signs can be manifestations of systemic alterations with vital importance for patients., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To determine whether patients who receive corneas from the same donor have similar risks of endothelial failure and rejection., Methods and Analysis: Patients with Fuchs endothelial dystrophy (FED) and pseudophakic bullous keratopathy (PBK) who received their first corneal transplant between 1999 and 2016 were analysed. Patients receiving corneas from donors who donated both corneas for the same indication were defined as 'paired'. Gray's test was used to compare the cumulative incidence of endothelial failure and rejection within 5 years post-transplant for 'paired' and 'unpaired' groups. Cox regression models were fitted to determine whether there was an association between recorded donor characteristics (endothelial cell density (ECD), age and sex and endothelial graft failure and rejection., Results: 10 838 patients were analysed of whom 1536 (14%) were paired. The unpaired group comprised 1837 (69%) recipients of single corneal donors and 7465 (69%) donors who donated both corneas for another indication. ECD was lower for unpaired single cornea donors (p<0.01). There was no significant difference in endothelial graft failure or rejection between paired and unpaired groups for FED (p=0.37, p=0.99) or PBK (p=0.88, p=0.28) nor for donor ECD, age, sex and paired donation after adjusting for transplant factors (across all models p>0.16 for ECD, p>0.32 for donor age, p>0.14 for sex match and p>0.17 for the donor effect)., Conclusion: The absence of a significant difference in graft outcome for corneal transplants for FED and PBK between paired and unpaired donors may reflect a homogeneous donor pool in the UK., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Purpose: The purpose of this study was to describe the genotypic and phenotypic characteristics of an infant with a SLC4A11 mutation associated with bilateral corneal edema, hearing loss, and hydronephrosis present since birth., Methods: This was a case report. Ophthalmic and systemic examination of the proband, histopathologic and ultrastructural characteristics of bilateral corneal discs, and molecular genetic evaluation by whole-exome sequencing are described., Results: A male infant was born with bilateral corneal opacities, sensorineural hearing loss, and hydronephrosis to healthy parents after an uneventful pregnancy. Penetrating keratoplasty of the left eye at age 10 months demonstrated minimal corneal edema with normal thickness Descemet membrane and cellular endothelium with intracytoplasmic vacuoles and degenerative changes in rare cells. Penetrating keratoplasty of the right eye 6 months later disclosed prominent corneal edema with a thickened posterior banded layer of Descemet membrane and severe endothelial atrophy. Whole-exome sequencing of the proband and parents' blood demonstrated a homozygous mutation in SLC4A11 gene (c.1735&#95;1737delCTC,p.Leu579del). The combined clinical, histopathologic, and molecular genetic findings raised consideration of an unusual phenotype of Harboyan syndrome manifesting as congenital hereditary endothelial dystrophy with a prelingual rather than, as previously described, postlingual hearing loss., Conclusions: We report a novel homozygous SLC4A11 variant with a previously undocumented phenotype of CHED in association with prelingual sensorineural hearing loss and hydronephrosis, thus broadening our understanding of the spectrum of genotypic and phenotypic findings of Harboyan syndrome., Competing Interests: Conflicts of interest statement: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Rationale: To report a case of bilateral transient corneal edema presumably associated with adenovirus-vectored coronavirus disease 2019 (COVID-19) vaccination that resolved with eye drops treatment., Patient Concerns: A 55-year-old Asian woman presented with sudden onset of bilateral visual disturbance developed 6 days after immunization with an adenovirus-vectored COVID-19 vaccine (AstraZeneca, London, United Kingdom). She underwent uneventful cataract surgery in right and left eyes 2 months ago and maintained good visual acuity bilaterally. Slit-lamp examination showed bilateral mild corneal edema that was confirmed with anterior segment optical coherent tomography. Anterior chamber and vitreous were clear bilaterally. Both fundi were normal., Diagnoses: The patient was diagnosed with corneal edema following adenovirus-vectored COVID-19 vaccination., Interventions: She was prescribed with prednisolone acetate 1% eye drops bilaterally., Outcomes: Treatment with topical steroid for 2 weeks resulted in resolution of the corneal edema and improvement of the visual acuity bilaterally., Lessons: This case suggests that transient corneal edema can develop following adenovirus-vectored COVID-19 vaccination. Prompt ophthalmologic evaluation and treatment may improve the corneal edema., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: To report rapid resolution of corneal clearing with the application of a modified technique of compression sutures in large hydrops., Methods: Interventional case series of seven patients., Results: Three patients had acute hydrops secondary to keratoconus, three had pellucid marginal corneal degeneration and another one had ectasia of undetermined etiology. A thorough slit-lamp evaluation and anterior segment optical coherence tomography was performed. The surgical technique involved paracentesis, anterior chamber decompression, compression suture placement within the stroma against the background of partial air fill in the anterior chamber, and bandage contact lens application. All eyes showed a remarkable reduction in corneal edema at 1 h (documented in four eyes) and 1 day (documented on the rest), which continued to improve in further follow up., Conclusions: The modified technique of compression sutures facilitate rapid recovery of corneal edema in acute hydrops seen in keratoconus and pellucid marginal corneal degeneration. The physiologic basis is akin to the external tamponade achieved with buckle in retinal detachment surgeries.

Purpose: The purpose of this study was to report a novel technique of donor lenticule insertion in Descemet stripping endothelial keratoplasty (DSEK) in aphakic corneal edema with large iris defect and without any posterior capsular support., Methods: This was a retrospective consecutive interventional case series. Clinical records of ten 1-eyed aphakic patients with corneal edema with large iris defect and no capsular support who underwent air-assisted donor lenticule insertion in DSEK were evaluated. After making 6.0- to 6.5-mm sclerocorneal tunnel and 2 side ports, limited anterior vitrectomy was performed if required. Then, Descemetorhexis was performed under air through side ports. Manually dissected donor lenticule was inserted into the anterior chamber under full-chamber air by a 30-G needle push-in technique. Further air tamponade was given if necessary. No fluid-air exchange was performed. The patient was kept on the same operating table for at least 1 hour and then shifted. Graft attachments in early postoperative period, corrected distant visual acuity, and endothelial cell density after 3, 6, and 12 months were analyzed., Results: The mean postoperative follow-up period was 19.2 ± 6.7 months. There was no donor dislocation in this small group. All patients achieved a corrected distant visual acuity of 0.70 (20/100) after 3 months and maintained until 12 months. The endothelial cell density at 3 months (n = 8) was 2028 ± 151/mm 2 , at 6 months (n = 7) 1776 ± 198/mm 2 , and at 12 months (n = 7) 1721 ± 172/mm 2 . The corresponding endothelial cell loss was 25.8% ± 5.6%, 34.4% ± 5.1%, and 37.8% ± 7.1%, respectively. One graft failed after 15 months., Conclusions: "Air-assisted" donor lenticule insertion in DSEK is a safe surgical technique in aphakic patients with corneal edema with large iris defect and no capsular support., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Acute corneal hydrops is a vision threatening complication of corneal ectasia like keratoconus, keratoconus, keratoglobus, Pellucid marginal degeneration, Terrien's marginal degeneration and post refractive surgery keratectasia. The associated risk factors for development of corneal hydrops (CH) are early onset of keratoconus, microtrauma associated with contact lens use, eye rubbing, allergic conjunctivitis, atopy, and Down's syndrome. With the conservative approach of management of CH, it takes longer time (in months) for corneal oedema to get resolved and there is development of vascularization and scarring. This video presents the simple technique of using compression sutures along with pneumodescemetopexy by intracameral air injection for management of CH. It led to rapid resolution of corneal oedema. It is a simple technique, with no need of special gases like C3F8 or SF6 and can be easily performed at a very basic set up., Purpose: To highlight the efficacy of simple technique of applying compression sutures and air tamponade in management of CH and to demonstrate the efficacy of anterior segment OCT in diagnosis and to assess the prognosis of a case of CH., Synopsis: A 9-year-old boy presented with CH, with anterior segment OCT showing torn descemet's membrane and fluid pockets in corneal stroma. Four full-thickness compression sutures were applied and intracameral sterile air was used for pneumodescetopexy. The serial post operative clinical and OCT picture showed rapid resolution of corneal oedema. Highlights: This video highlights the use of OCT imaging in the diagnosis of CH and full-thickness compression sutures as the safe and effective technique in the management of acute CH., Video Link: https://youtu.be/54C3hJB&#95;WTM., Competing Interests: None

Purpose: To assess risk factors contributing to corneal decompensation following glaucoma drainage device (GDD) implantation., Design: Retrospective case control study., Methods: Records of 1610 eyes that underwent GDD implantation between June 1, 2009, and April 1, 2020, at the Johns Hopkins Wilmer Eye Institute were reviewed. Seventy-nine eyes (5%) developed corneal decompensation, of which 46 underwent keratoplasty. These 79 cases were matched with 220 controls. Cox proportional hazard models with robust standard error estimates to account for clustering at the matched-pair level were used to assess risk factors for corneal decompensation. Kaplan-Meier survival analysis analyzed time to corneal decompensation., Results: The mean (SD) age of cases and controls was 68 (12.3) and 60.5 (15.9) years, respectively. The mean time from GDD implantation to corneal decompensation was 32 months, and the cumulative probability of developing decompensation at 3, 6, and 9 years was 4.7%, 9.2%, and 14.8%, respectively. Final visual outcomes in cases were worse, with a final mean ± SD visual acuity (logMAR) of 1.96±1.25 relative to a mean±SD visual acuity of 1.11±1.36 in controls (P < .001). In the multivariable model, significant risk factors for corneal decompensation were increased age (adjusted hazard ratio [AHR] 1.39, 95% CI 1.18, 1.63; P ≤ .001), history of Fuchs dystrophy or iridocorneal endothelial syndrome (AHR 9.18, 95% CI 5.35, 15.74; P ≤ .001), and postoperative complications such as hypotony (AHR 3.25, 95% CI 1.85, 5.72; P ≤ .001) and tube-cornea touch (AHR 6.37, 95% CI 3.77, 10.75; P ≤ .001)., Conclusions: The risk of postoperative corneal decompensation is persistent over time. Patients receiving GDDs, particularly those with advanced age, preexisting corneal pathology, and postoperative complications, should be counseled regarding their increased risk for corneal decompensation., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to investigate the association between corneal densitometry (CD) values from Scheimpflug tomography imaging, severity of guttae, and visual acuity in eyes with Fuchs endothelial corneal dystrophy (FECD)., Methods: This was a retrospective, cross-sectional study. Patients with FECD were examined at the Bascom Palmer Eye Institute from January 2015 to September 2019. We extracted CD values at central annuli of 0-2, 2-6, 6-10 and 10-12 mm from Scheimpflug tomography images. We investigated the association of corrected distance visual acuity (CDVA) with CD values, severity of guttae, central corneal thickness (CCT), cataract grade, refractive error, corneal edema grade, age, and gender using multivariate generalized estimating equation regression models., Results: One hundred ninety-two eyes from 110 patients were included in this study. Increase in central CD values at the 0 to 2 mm zone (P < 0.001), severity of guttae (P = 0.046), age (P < 0.001), cataract grade (P < 0.001), corneal edema grade (P < 0.001), and type of refractive error (P = 0.008) were significantly associated with decreased CDVA. Central corneal thickness, sex, and the peripheral CD values (2-6, 6-10, and 10-12 mm) were not significantly associated with CDVA (P > 0.05) in the final multivariate regression model., Conclusions: Our study demonstrates that central CD values at 0 to 2 mm and severity of guttae are each associated with decreased CDVA in FECD. These findings carry implications for patients with FECD considering surgical intervention for phacoemulsification alone, Descemet stripping only, or endothelial cell transplantation and provide a multifactorial perspective on vision loss in FECD., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To determine the relationship between the preoperative degree of corneal edema in the recipient and the endothelial cell density in grafts after Descemet stripping automated endothelial keratoplasty (DSAEK)., Methods: This retrospective case series enrolled 111 eyes of 107 patients who underwent DSAEK. The preoperative and postoperative central corneal thickness (CCT) was measured by anterior-segment optical coherence tomography. Eyes were divided into three groups according to the preoperative recipient CCT: group A (mild edema): 550 μm

Purpose: The purpose of this study was to report a case of microsporidial endotheliitis masquerading as graft rejection after deep anterior lamellar keratoplasty (DALK)., Methods: A 36-year-old man visited the clinic with complaints of blurred vision, redness, pain, watering, and whitish appearance of the black portion of his left eye. On evaluation, there was diffuse stromal edema with epithelial defect and hypopyon. Microbial keratitis resolved with macular grade scar. He underwent DALK. After 3 years, he presented with complaints of sudden diminution of vision in the same eye for 10 days. His unaided visual acuity was counting finger 1 meter. The clinical findings were circumcorneal congestion, diffuse graft edema, Descemet membrane folds, and diffuse keratic precipitates. A presumptive diagnosis of left eye graft rejection was made. Topical steroids were administered. There was significant improvement within a week. However, at 1 month, there was an increase in graft edema after the steroids were tapered. At this point, a diagnosis of endotheliitis of viral origin was made. He was then administered oral antivirals and steroids. There were 2 such waxing and waning episodes of graft edema before the graft failed. Patient underwent penetrating keratoplasty with cataract extraction with intraocular lens implantation., Results: The previous donor and host Descemet endothelium complex was sent for histopathology and polymerase chain reaction. Both histology and polymerase chain reaction were positive for microsporidia., Conclusions: Microsporidial endotheliitis may present as graft rejection. There should be a suspicion of microsporidial infection in cases of features mimicking as endothelial rejection after DALK., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: The presence of Descemet membrane scrolls is an uncommon finding reported in syphilitic interstitial keratitis. We herein describe a novel surgical strategy for this entity; this report demonstrates that Descemet membrane endothelial keratoplasty surgery can be performed with excellent visual outcomes in the event of corneal edema as a late sequela of syphilitic keratitis., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Descemet's membrane (DM) rupture/detachments have traditionally been treated conservatively, with limited efficacy and a long rehabilitation period that significantly affects patients' vision and quality of life. Although there are no established gold standards for the timing and nature of treatment, with this series of 4 cases we aimed to highlight the importance of the current optimal intervention methods. The first two patients were treated with anterior chamber injection of isoexpansile 14% C3F8 due to acute hydrops associated with keratoglobus in the first case and keratoconus in the second case. The third patient had keratoglobus and chronic hydrops complicated by multiple stromal clefts detected on anterior segment optical coherence tomography, and the fourth patient had a chronic broad DM detachment which occurred after cataract surgery. Both of these patients were treated with intracameral C3F8 injection together with corneal compressive sutures. In all four cases, DM reattached completely and effectively with surgical intervention. Surgical management of DM rupture/detachment with intracameral gas injection and compressive corneal sutures seems to provide fast symptomatic relief and less healing-related corneal scarring with better visual rehabilitation, and may alleviate the need for corneal transplant surgery in this group of patients.

Aim: To describe the long-term outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) with an anterior chamber intraocular lens (ACIOL) compared to secondary posterior chamber (PC) IOL., Methods: This was a retrospective comparative cohort study. The clinical data of 82 eyes from 82 consecutive patients with pseudophakic (PBK) or aphakic bullous keratopathy (ABK) who either underwent DSAEK with retained or secondary ACIOL (n=23) or DSAEK with IOL exchange and/or secondary PCIOL (retropupillary iris-claw IOL, n=25; intrascleral-fixated IOL, n=29; or sulcus IOL, n=5) were analysed. The main outcome measures were graft survival and complications up to 5 years., Results: The graft survival in the secondary PCIOL group was superior than the ACIOL group over 5 years (year 1, 100.0% vs 100.0%; year 3, 94.7% vs 75.0%; year 5, 91.1% vs 60.6%, p=0.022). The presence of an ACIOL was a significant risk factor associated with graft failure (HR, 4.801; 95% CI, 1.406 to 16.396, p=0.012) compared to a secondary PCIOL. There was no significant difference in the rate of graft detachment and elevated intraocular pressure between the groups. There were five cases (9.3%) of IOL subluxation or dislocation in the retropupillary iris-claw and intrascleral-fixated IOL groups., Conclusions: Eyes that underwent DSAEK with ACIOL in situ had poorer long-term graft survival compared with those with secondary PCIOL. Intraocular lens exchange was not associated with a higher complication rate. In ABK or PBK eyes with ACIOL, we recommend performing IOL exchange and/or secondary PCIOL implantation combined with endothelial keratoplasty., Competing Interests: Competing interests: DT and JM, inventors of the EndoGlide, have financial interests in the device (AngioTech, Reading, Pennsylvania, USA/Network Medical Products, North Yorkshire, UK)., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Epithelial downgrowth is a rare complication after Descemet stripping automated endothelial keratoplasty (DSAEK), which usually leads to poor visual outcome despite multiple available options of treatment., Case Presentation: A 50-year-old man underwent DSAEK procedure due to pseudophakic bullous keratopathy. Three months later, the patient presented with gradual visual loss; slit-lamp examination revealed detachment and folding of the DSAEK lenticule, which was confirmed by anterior segment optical coherence tomography. On confocal scanning, epithelial cell sheets were detected in the interface leading to the wrinkling of the donor tissue and donor detachment. Surgical debridement and transient fixating with straight 10-0 prolene needles were performed followed by air injection into the anterior chamber. The cornea turned clear in the one-year follow-up with uncorrected-visual acuity of 20/30 and best-corrected visual acuity of 20/25., Conclusions: Early diagnosis and treatment of epithelial downgrowth may be associated with a good prognosis and prevent from more aggressive treatments such as repeat of grafting. In this case, mechanical debridement and transient fixation of lenticule by 10-0 prolene needles was performed to manage post-DSAEK epithelial downgrowth and lenticule detachment, which was successful without requiring of additional re-grafting. It seems this is a feasible technique with acceptable long-term outcomes., (© 2022. The Author(s).)

Purpose: To evaluate the morphological features of posterior corneal layers in pseudophakic bullous keratopathy (PBK) and Fuchs endothelial corneal dystrophy (FECD)., Material and Method: The study included 20 patients (20 eyes) aged 73.8±7.8 with PBK and 24 patients (25 eyes) aged 72.5±10.6 with FECD. Central corneal thickness was measured in all eyes before the surgery by anterior segment optical coherence tomography (AS-OCT, RTVue-100, Optovue, USA). All patients underwent corneal transplantation (DSAEK or DMEK). Postoperative donor graft status was assessed as attached or detached by AS-OCT (RTVue-100, Optovue, USA). Specimens of Descemet's membranes (DMs) were obtained intraoperatively and investigated histologically (hematoxylin and eosin staining). Morphometric analysis was performed using optical microscope Leica DM-2500 (Digital Color Camera Leica DFC295) and ImageScope M software., Results: There was no difference in thickness of DMs' prenatal anterior banded layer (2.58±0.49 μm) and postnatal posterior non-banded layer (11.30±2.64 μm) between PBK and normal cornea. In FECD eyes, DM was significantly thickened by additional collagen layer and guttate excrescences (postnatal layer thickness - 16.62±4.34 μm). Morphological study of the DMs of patients with graft detachment in the early postoperative period revealed residual stromal collagen fibrils that were fixed to the area with dense extracellular matrix., Conclusion: The study shows that chronic corneal edema is associated with pathological morphological changes in the posterior corneal layers in PBK and FECD. Individual features of the dense extracellular matrix in the DMs may play a key role in the attachment of donor graft to the corneal stroma and affect the postoperative outcome.

Purpose: To compare two surgical treatment options for acute corneal hydrops in keratoconus: Mini-DMEK versus predescemetal sutures., Methods: Sixteen patients were treated by either Mini-Descemet membrane endothelial keratoplasty (Mini-DMEK) (n = 7, group 1) or predescemetal sutures (n = 9, group 2) early after onset of acute hydrops. Visual acuity, maximum corneal thickness (SD-OCT) in the affected oedematous area, complications and recurrence rates were retrospectively compared between both groups. Measurements were taken immediately preoperatively as well as 1 day, 1 week and 1 month postoperatively (Table 1)., Results: Both groups showed reductions in corneal thickness and increased visual acuity shortly after surgery. In group 1 (average age 33 years ± 7 years), the best corrected visual acuity (BCVA) increased from logMAR 1.65 ± 0.7 before Mini-DMEK to logMAR 0.93 ± 0.6 30 days after Mini-DMEK (p = 0.046). During that period, maximum corneal thickness decreased from 1159 ± 338 µm before surgery to 531 ± 75 µm after Mini-DMEK (p = 0.046). Patients from group 2 (average age 34 ± 10 years) had a BCVA of logMAR 1.59 ± 0.8 which increased to logMAR 0.97 ± 0.5 (p = 0.014) 30 days after surgery. At the same time, the preoperative maximum corneal thickness decreased from 1439 ± 272 µm to 476 ± 162 µm (p = 0.014). There was no difference in corneal thickness or BCVA one month after the surgical intervention between both groups (p = 0.394 and p = 0.871)., Conclusions: Both techniques, Mini-DMEK and predescemetal sutures, are effective in the treatment of an acute hydrops in keratoconus. Mini-DMEK appears to be beneficial in large DM tears., (© 2021 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)